Articles

Talk About Pressure …

This article appears on the Journal of the American Academy of Physician Assistants’ blog, Musings.

As scuba divers, my wife and I learned how to calculate bottom times, single-tank limits and more. We were thoroughly informed of the whereabouts of the nearest hyperbaric chamber (at a tertiary medical center some 65 miles away), and how to avoid ever, ever needing one: Always exhale while ascending, no rapid ascents, except in an emergency, and don’t exceed your calculated bottom time. Fortunately, the only near-emergency we ever encountered was on our very first dive together, nearly 45 years ago. We were diving in about 80 feet of water in one of the Finger Lakes of upstate New York, swimming in and out of an old paddlewheel boat that sank in the late 1800s. Suddenly, my wife gave me the no-air sign—a hand swipe across her throat. We came together and “buddy-breathed” off my regulator while we slowly ascended. I was so proud of her … and proud of our training. (OK, I was one of the instructors.) But I digress. No hyperbaric chamber necessary—just the replacement of a well-used regulator that had jammed.

Recently, we went snorkeling in 15 to 20 feet of warm ocean water a few miles off Honolulu, Hawaii. We wanted to see the huge sea turtles up close. And it was wonderful! I reached out and petted one on the head, earning me some closeup touching of its shell, and an angry tirade from our divemaster, who later reminded me of the potential huge fine for messing with a protected species.

The sun was beginning to descend as our dive boat returned to shore. Suddenly, we hit a large Pacific wave, and I skidded across the deck, avulsing a large chunk of flesh from my right great toe. It bled and bled, freaking out my fellow divers and my wife. But the captain was prepared and equipped, and after yards of gauze and a hosing down of the deck, we were again headed toward Honolulu. In spite of my best self-care as a seasoned PA, by the time we arrived home in Las Vegas, I knew I was infected. My leg was red, hot, swollen and painful. I telephoned my primary care provider, who told me to come right in. He cultured the wound, re-bandaged it and started me on large doses of trimethoprim/sulfamethoxazole (I’m allergic to penicillin.) I saw him in 48 hours and looked at the culture results: methicillin-resistant Staphylococcus aureus (MRSA)! My next stop was the wound care center at a nearby hospital. The attending podiatrist carefully and deeply debrided the wound. She ordered plain radiographs and an MRI to rule out osteomyelitis. The radiographs did not reveal osteomyelitis, and I was relieved. She, however, noting that I had what my patients call “a touch of sugar,” advised me that her instincts told her I had osteomyelitis, in spite of the negative diagnostic tests. She proceeded with an open bone biopsy on the spot. Her 25 years of experience and finely tuned instincts served her (and me) well. I did in fact have osteomyelitis.

And this is where we come to the reason for the title of this blog post: The physician said that, if I wanted a good chance of keeping the toe, I needed hyperbaric oxygen (HBO) chamber therapy. She brought me into the present decade by telling me that nearly every city hospital-based wound care center has its own HBO chambers—no more 65-mile commute like in the early days. And these days, the treatment is used for far more than decompression sickness.